The Producer Reproducer Ratio

Math – for many, mere mention of the subject sends chills down the spine. However, in the case of the Producer Reproducer Ratio, it isn’t the math that’s scary – it’s the implications.

The Producer Reproducer Ratio or, PRR, is a concept I came up with a few years ago in an effort to explain a point to a friend regarding the economics of childrearing. I derived the notion from my mother’s oft repeated comment in which she said “The nine months it takes to get ‘em here is easy, it’s the eighteen years it takes to raise ‘em that’s hard.” Having had six children of her own, I consider her a bit of an authority on the subject.

The PRR explains a fundamental concept of the economics of childrearing by converting my mother’s wisdom into a social mathematical principle. Every human being requires a certain amount of resources (food, clothing, shelter, medical care, etc.) during his or her lifetime. It is the responsibility of parents to provide these resources for their child until such time as that person can provide for himself or herself. The problem, of course, is that many people who are biologically capable of reproducing are unable or unwilling to produce the resources the child requires, thus shifting that burden to someone else.

Now comes the math (try not to panic): say a set of parents reproduces (R) one child (R = 1) and the parents are required to produce (P) the total amount of resources that one child requires for the first 18 years of life (P = 1). As long as the parents produce the necessary amount of resources for that child, P = R or, expressed as a ratio, 1:1. And that’s the way it works in most families. However, problems arise for instance, when the parents only produce half the resources the child needs, resulting in a change in the ratio to 0.5:1. In this case, someone other than the parents must provide the remaining resources. Occasionally, these parents are able to turn to other family members or friends but, all too often, the burden of making up the shortfall is passed along to the taxpayers.

Consider a more extreme example: say a set of parents has three children (R = 3) with the means or motivation to provide for only one of them (P =1) resulting in a PRR of 1:3. The bigger the R, the bigger the problem. As long as P = R, no shortage of necessary resources exists – parents are pulling their weight and properly providing for their children. When R exceeds P, shortages of resources arise and either the parents receive help from outside sources or the child goes lacking.

An alarming trend in our society is the growing rate at which R is exceeding P. Too many parents, usually young, poorly educated, often unmarried and ill-equipped to alter their own life circumstances, are having children with little or no regard for the provision of their most basic needs. Most assume the state will provide for their children. And why wouldn’t they assume such given the acculturation of entitlement to which so many of today’s young people have been exposed?

The PRR may remind us of a dull, dry, uninteresting mathematical formula we were required to learn in high school only to selectively forget the minute we graduated. In truth, it is a numerical reflection of an alarming social trend plaguing modern America. The choice to have a child is the most monumental decision a person can make in his or her lifetime. Regrettably, the biology of reproduction is all too often unaccompanied by the motivation for resource production. No decent person wants to see a child go lacking the essentials of everyday life. We recognize, after all, that the child isn’t at fault. However, by continuing to send the message that it’s okay to have children without consideration of, or provision for, their needs, we merely encourage the behavior.

Further, those who so flippantly disregard the daily needs of their children often fall far short in other areas of effective parenting as well. For the sake of the children, it is important to send the message that having them is acceptable only in the context of being prepared to properly care for them. Merely loving a child isn’t enough. Being a good parent is hard and, from time to time, even requires learning a little math beginning with the Producer Reproducer Ratio.

What You Don’t Know About America’s Health Care System Can Hurt You

As a physician practicing full-time emergency medicine, I’ve spent thousands of hours treating patients in an acute care setting. During that time, I’ve seen America’s health care system at its best – lives saved, diseases cured, health restored. The daily contribution by our health care system towards the reduction of human pain and suffering is incalculable. American health care is unparalleled in the developed world and, without doubt, if a person is sick or injured, America is the place to be.

Regrettably, however, America’s health care system has a dark side as well – one populated by those who abuse themselves by abusing street drugs, alcohol, or prescription pain medications, those who chronically make poor lifestyle choices, and those who are generally out to beat the system. This dark side of America’s health care system is a side that, as a health care provider, I know all too well, yet, ominously, it’s a side many Americans don’t even know exists. Nevertheless, whether one is aware of this dark side of American health care or not, it’s a side that can hurt us all.

Average Americans are actually very decent people – hardworking, dependable, responsible, compassionate, charitable, and concerned about their fellow citizens. Further, the average American isn’t a substance abuser, doesn’t consistently make poor lifestyle choices, and isn’t out to get something for nothing. In fact, such activities are so typically foreign to them as to be beyond their awareness and even comprehension. Therefore, it often comes as a surprise to many of these average Americans when I recount the myriad stories of waste, fraud, and abuse I witness daily in the emergency room.

For instance, not so long ago, I treated a middle-aged woman who presented to the emergency room with a complaint of low back pain. The patient was well known to the ER staff, having been to that particular emergency room 43 times that year alone, of course, all at taxpayer expense. Her story was that someone had stolen her pain medication which she needed for a chronic back problem. Typical of this common scenario, the patient stated she hadn’t been able to see her doctor for a refill. When I asked her to describe the nature of her back problem, she couldn’t. When I asked what her MRI had shown, she explained that she’d never had one – the reason being that she missed her appointment. When I told her I would like to speak to her doctor, she proceeded to tell me she had recently stopped seeing her previous doctor and was in the process of finding a new one but hadn’t gotten around to it yet. Needless to say, I declined to write her a prescription for her pain medication after which she called me a few choice names of the four-letter variety.

The same night, another middle-aged woman arrived via ambulance to the emergency room. She was complaining of chest pain. It was her seventh ambulance transport to the ER that month – seventh – each time complaining of chest pain. Each time her cardiac workup was negative, yet, each time her urine drug screen was positive for cocaine. Though she had a healthy heart, the stimulant effect of the cocaine induced heart strain which resulted in significant pain and discomfort. Nevertheless, we were bound to perform a complete cardiac workup – the seventh that month – to the tune of many thousands of dollars, again, of course, at taxpayer expense.

Frustratingly, the above stories are so commonplace in emergency rooms across the country that they’ve essentially become clichés barely raising the eyebrows of health care providers. In fact, the problem is so extensive that few believe anything can be done to correct it. The waste, fraud, and abuse plaguing America’s emergencies rooms, a problem I’ve spoken about often and written about in the past, is costing productive Americans billions of dollars annually. I’ve long believed that if a portion of those wasted funds could be recouped by the government, Uncle Sam could afford to purchase private insurance coverage for every man, woman, and child in America.

And, yet, nothing is being done. Why? Several reasons. First, those who draw attention to the fact that certain patients abuse the health care system, particularly emergency rooms, are quickly labeled as uncompassionate. Further, medicine is a complex field and those with the expertise to suggest meaningful solutions to its many problems are generally outside the legislative process. In addition, with the ever-present threat of litigation hanging over its head, the health care industry is hesitant to even approach the subject of meaningful reform for fear of becoming mired in future lawsuits.

However, those concerns are no excuse for inaction. The health care reform America desperately needs is not in the form of socialized medicine but rather in legislation that promotes responsible utilization of our health care resources. In an emergency situation, in particular, inappropriate utilization of health care resources puts all Americans at risk. Imagine your mother, or husband, or best friend dying of a heart attack while awaiting the arrival of an ambulance that is delayed because it is being used to transport a crack addict to the hospital for the seventh time in a month. It’s time for Americans to get the word on what’s happening on the dark side of our health care system. After all, it’s what you don’t know about the American health care system that can hurt you.

Stop Blaming The Teachers

Since America’s earliest days, education has consistently ranked at or near the top of the list of priorities most important to its citizens. Americans, in general, regard education as the single most valuable contribution we can make to the betterment of our children’s lives and to the overall long term health of the nation. Every year, America invests billions of dollars in our educational system from the primary and secondary levels to the college and graduate levels and beyond. As a result, America consistently produces many of the brightest, most educated, and most capable children in the world who go on to reach great heights of educational and professional achievement and lead meaningful, productive lives.

But what about the other kids?

Regrettably, however, many of America’s children miss the boat educationally, so to speak, and, therefore, fall far short of their potential. Americans are so concerned about this lamentable situation that the subject is constantly in the minds and on the tongues of political leaders, media personalities, pundits of every sort, and average Joes gathered around the coffee pot every morning at work. Theories abound as to the cause of the dilemma – not enough money spent on education, too many kids in the classroom, lack of local control of education, etc., etc., etc. Unfortunately, some even blame the teachers. Undoubtedly, the cause is complex and multi-factorial, however, with this last theory, in particular, I heartily disagree.

It never ceases to amaze me when I hear stories of out of control children reeking havoc in America’s classrooms. Stories abound of kids bringing guns to school, or getting busted on campus with crack cocaine in their pockets, or incidents involving educators being physically assaulted at school by aggressive, criminally-minded teenagers. What amazes me even more, however, is that after all that, teachers continue to teach. Holding their students’ welfare above their own, many educators continue to run the daily gauntlet of student apathy, misconduct, and open aggression in an effort to reach as many of their students as possible and, in so doing, often put themselves at great risk of harm – both emotional and physical.

Of course, having been an observer of our educational system for many years, both internally and externally, not to mention the fact that one of my sisters is a teacher and that I have many friends in the teaching professions, I have my own theories. I don’t believe the problem lies in a failure to spend enough on education. I believe we spend plenty. In fact, educational expenditure is often a poor predictor of outcome as many developed nations around the world spend less money per student and, yet, have higher performance on standard educational assessments.

I believe, rather, that lack of local control of educational systems, too much government regulation, and too many children in the classroom are factors much more deleterious to educational success than the amount of money spent per child. An even greater problem, in my opinion, is diversion – which is to say, too many diversions. Children these days have so many diversions (cell phones, concerns about fashion, sexual aggressiveness among certain students, drugs, peer pressure, etc.) that it isn’t at all difficult to understand their lack of focus on education.

Several years ago, I participated in a US-sponsored humanitarian relief mission in Nicaragua in which my unit built two schools and a clinic. Everyday at the work sites where the schools were being built, children from the local community gathered around and “played” school in the shade of the trees. They were so excited about having a school that they actually gathered there before the school was completed. They had few diversions – they were focused on the opportunity to go to school, so much so, that they pretended they were already in school before the schools even opened. That enthusiasm for education, I believe, is missing among many of America’s school-aged children and I believe the cause is too many diversions.

Nevertheless, whether I’m right or wrong on my theory of diversion, I’m convinced I’m right that teachers, in general, are not to blame when children fall short of their educational potential. In fact, I believe teachers are to be commended for continuing their struggles to overcome the diversions that distract children from their studies. Certainly, there is the occasional teacher that is subpar, but I believe that is the exception rather than the rule. It’s time to reaffirm our belief in, and support of, our teachers. They must know they have our confidence and our understanding. A teacher’s job is tough, especially these days with so many diversions competing for student’s attention. We need to help teachers and students alike by attempting to minimize the impact of these diversions so children can focus on their educations. And, most important of all, we need to stop blaming the teachers.

The \$10 Aspirin

Why do hospitals charge 10 bucks for an aspirin? If you’ve ever been a patient in a hospital, you’ve probably asked yourself that very question after reviewing your bill. And it’s a valid question. After all, if you can buy a bottle of aspirin at the drug store for pennies per pill, why, then, does a hospital find it necessary to charge 10 dollars for one? Is it a rip-off, a scam perpetrated on ill and vulnerable patients by heartless hospital administrators bent on making a profit regardless of the economic hardship thrust upon individual patients and society at large? Hardly. As angry as you might be at the notion of a hospital charging \$10 for an aspirin, the reason they do so will truly make your blood boil.

Hospitals determine what to charge for an aspirin through a process called “cost accounting.” It’s a complex process that “accounts” for, or assigns, costs to the myriad steps involved in getting an aspirin from the manufacturer to your blood stream. First of all, the hospital must purchase the aspirin – likely a nominal cost in itself due to the hospital’s bulk purchasing power. But, then, a worker in the receiving department or pharmacy must unpack the aspirin (bottle) and store it in the proper place within the pharmacy. When an order comes in for an aspirin, a pharmacist or pharmacy technician must retrieve the aspirin and forward it on to the patient’s floor (some hospitals have a medication storage device on the wards from which nurses can retrieve medicines directly but these still must be stocked by a pharmacist or pharmacy tech).

Eventually, a nurse obtains the aspirin and gives it to the patient. She or he must then catalogue the act of dispensing the medicine in order to establish a record or “paper trail” of the act itself. From time to time, other hospital personnel review patient charts in order to confirm that the appropriate medicines were, in fact, dispensed. As mentioned above, the act of giving a patient an aspirin (or any other medicine for that matter) is a complex process with associated costs beginning with its purchase and extending even beyond the point at which the patient swallows the pill. As many as ten people, or more, are often involved in what otherwise seems to be a rather simple process. All these costs must be met and all these people must be paid (including hospital overhead such as utilities, supplies, maintenance and repairs, new equipment purchases, etc.).

Nevertheless, although the apparently simple act of giving an aspirin to a patient is, in fact, a complex and expensive process, it still only “accounts” for less than half the total cost of the aspirin – say \$3 or \$4 of the total \$10 cost. So, from whence do the additional charges arise? Yep, you guessed it – from those patients who ultimately don’t pay their bills. There are, as the old saying goes, “no free lunches.” Someone has to pay those unpaid bills. These costs are spread among other charges within the hospital, such as the \$10 aspirin. So, in truth, it isn’t the hospital’s fault for an aspirin costing \$10 but, rather, those patients who cannot, or simply choose not, to pay their bills.

A substantial percentage of these non-pay patients are seen in America’s emergency rooms. In fact, unpaid bills arising from the emergency room are often a hospital’s largest annual unpaid expense. And hospitals across America are struggling under the economic strain caused by non-pay patients inappropriately utilizing emergency rooms for non-emergency conditions such as colds, insomnia, or chronic aches and pains, and medication refills. Such non-emergency conditions should be handled at the patient’s doctor’s office. But visiting a doctor at his/her office often means paying a nominal co-pay. Why would a patient do that when they can just go to the emergency room for “free?”

In this age of “healthcare reform,” the regrettable truth is that the government has missed (or chosen to ignore) a key point in the overall problem of rising health care costs – that inappropriate utilization of health care resources by those having no intention whatsoever of paying for them is a major factor driving the rise in health care costs. Until these individuals are forced to assume financial responsibility for their own health care needs, productive Americans will continue to bear the burden of these costs.

Why do politicians continue to ignore this obvious and egregious problem? Because it is politically uncomfortable for them. Most politicians are concerned, first and foremost, about their re-election. Therefore, they don’t want to risk alienating part of their constituency by supporting measures that would require these patients to become responsible consumers of health care resources like the rest of us. Until these politicians alter their focus and become true leaders, we can expect to continue paying \$10 for an aspirin.

The Two Great Failures Of The Legislative Branch

In a supreme act of both insight and foresight, America’s Founding Fathers established the greatest system of government the world has ever known – bar none. From its most humble beginnings, our American republic has become what President Reagan famously called a “shining city on a hill,” and is considered the benchmark of self-government the world over. The sometimes delicate, sometimes rugged system of checks and balances they created has withstood countless challenges from economic catastrophes to social upheavals to presidential assassinations to world wars and, rather than being diminished, has each time emerged stronger.

Nevertheless, in spite of our government’s obvious strengths, each branch possesses certain flaws that reduce its overall effectiveness. Of the three branches of our republican system of government – legislative, executive, and judicial – it is the legislature that suffers the greatest of these flaws. In fact, at least two such flaws – the lack of term limits for its members and the ability to attach myriad unrelated pieces of legislation to important bills – are so profound they actually constitute failures of the branch itself.

Though he was beloved by millions of Americans, elected officials saw President Roosevelt’s repeated election to the presidency (he was elected four times, dying in office shortly after beginning his fourth term) as a threat to democracy itself. As a result, the 22nd Amendment to the Constitution, ratified February 27, 1951, limited to two the number of terms any person may serve as president. Curiously, these same legislators (and most legislators since) failed to apply the same logic to their own offices.

Congress and the many state legislatures across America are filled with people who’ve served multiple terms – some for 20 or 30 years or even longer. This is actually anti-democratic on at least two levels. First, the longer these people serve, the less likely other qualified candidates are to run against them. The result is a diminishment of democracy itself as voters ultimately experience less choice in government. This situation serves well the elected official, but not the electorate. Democracy is further damaged by the tremendous influence long-serving politicians accumulate through relationships with various individuals and special interest groups developed during their tenure. The old saying, “Power corrupts and absolute power corrupts absolutely,” applies in these situations as such influence often leaves politicians unaccountable to the voters.

Otto von Bismarck is attributed (possibly erroneously) with the saying, “Laws are like sausages, it is better not to see them being made.” Whether the German statesman actually made that famous quote or not, the message is clear – legislating is a dirty business. However, it isn’t the act of debating the merits of a particular piece of legislation that is so dirty but, rather, the back room deals, the whispers in the hallways, the winks and the nods that are so offensive to the notion of representative democracy – a.k.a., a republic. It is these seedy, underhanded dealings, which many elected officials consider a matter of course, that are an affront to American voters who put their faith in the electoral process and representative government. These acts are, in fact, anathema to “government of the people, by the people, for the people.”

A by-product of long-serving politicians is the strangle hold that certain of these people have on the chairmanships of important legislative committees such as appropriations. No single person should hold these seats year after year after year. The result is a concentration of power that leaves other legislators (and, therefore, other regions of the country) beholden to the whims and wishes of the chairman.

Even worse, however, than the unfair concentration of power and influence resulting from the lack of term limits is the utter catastrophe of representative government that stems from the legislature’s ability to attach completely unrelated provisions to important pieces of legislation. In fact, this legislative tactic constitutes the greatest single weakness of the entire legislative process in that, rather than risk failure of important legislation, legislators will accept nearly any attachment regardless of how esoteric or irrelevant in an effort to gain passage of the larger bill. Through this means, representatives and senators succeed in funding countless pork barrel projects designed to assure their re-election. And, of course, it’s all at taxpayer expense.

Instituting term limits and curtailing the attachment of irrelevant legislation to important bills in the House and Senate would do much to restore faith in our system of government by enhancing its equitableness and cost effectiveness. However, regrettably for the American electorate, legislators benefit far too much to correct these two great failures of the legislative branch.

Nation Of Americans, Not Immigrants

It’s one of the liberal national media’s most beloved and oft repeated phrases – “We are a nation of immigrants.”

Well, sorry to let the cat out of the bag but, actually, no we’re not. We are a nation of Americans. Of course, it’s true there are a lot of first-generation immigrants here, however, don’t be fooled by repetitive liberal rhetoric designed to indoctrinate you into their way of thinking – the number of bona fide, non-immigrant Americans far exceeds the number of those newly arrived on our shores.

To test my point, perform a little experiment – first of all, think about yourself and your own family and ask yourself these simple questions: “Was I born here?” If the answer is “Yes,” then you’re not an immigrant. Next, ask: “Were my parents born here?” If the answer to that question is also “Yes,” then your parents aren’t immigrants either. For me, I can ask that question sequentially of my ancestors with the answer being “Yes” at least eight times which is as far back as my family has ancestry records. The point is that I’m not an immigrant, nor are my parents, nor my grandparents, nor my great-grandparents, nor my great-great-grandparents, nor, well, you get the picture.

Now, to further test my point, consider your friends and co-workers – were they born here? Chances are the answer is “Yes.” And chances are their parents were born here as were their grandparents as were their great-grandparents as were, well, again, you get the picture.

In fact, the total number of true first-generation immigrants in America today isn’t even close to the total number of bona fide, non-immigrant, multi-generational Americans living in this country. So why does the liberal media persist in attempting to convince us that we are a “nation of immigrants?” Lots of reasons.

The most important reason is political – the Democratic Party holds itself out to be the “party of the immigrant.” Stories of Tammany Hall operatives standing on the docks of New York harbor in the 1800s and early 1900s encouraging, and even coercing, Irish-immigrants as they exited the boats to “vote democratic” are legendary. Immigrants have long served as a source of new voters for the Democratic Party. The liberal Left, long the mouth-piece of the Democratic Party, continues to promote the “party of the immigrant” notion through its pro-immigrant rhetoric. But truth is, the Democratic Party doesn’t so much love immigrants as it loves their votes.

Another lesser reason for the liberal Left’s persistent pet phrase is political correctness – in stating openly and repeatedly that we are a “nation of immigrants,” the Left is attempting to create a sense of acceptance of immigrants (especially illegal ones), thus diffusing many of the practical issues concerning immigration including, most importantly, illegal immigration. By repeating the phrase over and over and over, the Left is attempting, through the power of suggestion and conditioning, to induce the average American to over-identify with immigrants, thus becoming lulled into a sense of complacency about immigration issues.

Now, it’s important for the reader to understand that I am not a xenophobe – I don’t have anything personally against any “legal” immigrant. For those immigrants who come to this country legally, work hard, and play by America’s rules, I say, “Good luck and more power to you.” It’s also important for the reader to understand, however, that I believe “illegal” immigration in this country is more than just a problem, it’s an outright calamity. Further, because I’ve long dismissed “political correctness” as a bogus liberal ideological construct, I’ve never been afraid to recognize illegal immigration for what it is – a dangerous influence in our society.

Of course, those of a liberal mindset would attempt to dismiss my views on immigration issues as unfounded except, of course, for the fact that I understand immigrants and immigration better than most – you see, there were and are first-generation immigrants in my own family. Though he died tragically in a motorcycle accident in 1981, a former brother-in-law of mine was born in Mexico, given up for adoption, and raised in the United States. Before his death, he and my middle sister had three children – he was a favorite of my family, adored then and missed now. I have another brother-in-law, alive and well, who immigrated to America from Pakistan in the early 1980s. He and my youngest sister married not long after his arrival and they also have three children. He, too, has been a favorite of my family for many, many years.

The difference, of course, is that my brothers-in-law played/play by the rules – they were/are proud of their heritage but were/are more proud of being Americans. They came here legally, embraced American values, worked hard, and didn’t wear their immigrant status on their sleeves, waving it as a banner under the noses of those Americans like me and most of you who were born here.

So, the next time you hear someone on the Left attempt to indoctrinate you by saying, “We are a nation of immigrants,” say to yourself and those around you, “Hardly,” and recognize the truth that, even though there are many immigrants here, we are actually a “nation of Americans.”

A Wall That Mends

In his famous poem, “Mending Wall,” Robert Frost’s neighbor says to the poet during their annual ritual of rebuilding the stone wall between their property, “Good fences make good neighbors.” Most people agree that walls are good for neighbors, but when it comes to nations, some are sitting on the proverbial “fence.”

The recent debate regarding the value of building a fence along the border between the United States and Mexico provides an example of this dilemma. Some argue that the wall is a necessary first step toward stemming the flow of illegal aliens flooding across our southern border while others contend a fence is unnecessary and “sends the wrong message.”

As for me, I hold with those who support building the fence. Here’s why: First of all, although we are a nation of immigrants, we are, much more importantly a nation of laws. Illegal immigrants, and those who support them, completely ignore our laws. Existing U.S. immigration legislation provides a mechanism for legal immigration into this country. However, because abiding by these laws requires time and effort, illegal aliens choose to ignore them.

Secondly, illegal immigration could potentially jeopardize our national security, thus placing every American at risk. It’s no secret that members of various terrorist organizations have declared war on America. As security at airports and seaports around the country increases, these terrorists will undoubtedly seek other routes of entry into the U.S. Our largely unprotected southern border will eventually become, if it hasn’t already, a logical entry point.

Thirdly, contrary to popular belief, our economy suffers in myriad ways as a result of illegal immigration. To begin with, the vast majority of illegals don’t pay taxes on their income, thus significantly reducing government revenues. The burden of this lost revenue is shouldered by taxpaying-Americans in the form of higher income taxes. Furthermore, since illegal aliens send home most of the money they earn in the U.S., billions of dollars are being removed from our economy annually. Additionally, the influx of low-skilled workers overly expands the available workforce, thus eliminating the incentive for employers to increase the minimum wage and reducing the earning potential of young and/or low-skilled American workers.

Finally, the sheer number of illegal aliens overburdens our infrastructure and drains our resources, especially regarding health care. For every dollar that illegal immigrants put into the U.S. economy, many more dollars are taken out.

Recently, in an effort to cast their argument in a more favorable light, advocates of illegal immigration have referred to President Reagan’s famous Berlin Wall speech in which he admonished Soviet President Gorbachev to “tear down this wall.” The point they sorely miss is that the Berlin Wall was built to keep people in, not out. The opposite would be true of America’s wall – it would be built to protect, not oppress.

Good neighbors may need good fences, but good nations shouldn’t. Unfortunately, in their refusal to do anything to stop their citizens from illegally entering our country, our neighbors to the south have demonstrated they have no intention of being good. Hopefully, our wall will send a clear message – that immigrants must respect our laws and enter our country legally. Only then will our wall be seen as a wall that mends, rather than divides.

A Litany Of ER Abuses

A Litany Of ER Abuses

In a recent column, I discussed the forthcoming closure of the Cook Medical Center ER and why it shouldn’t be happening. Unexpectedly, at least to me, that column appears to have gone “viral.” Of the tens of thousands of people reached, surprisingly, I received only three negative responses – all of which I found rather amusing. One person referred to me as “anti-Christian” (really?). Another stated that “grouping people into groups” was wrong (self-explanatory). And, yet, a third explained how aghast she became when she discovered that her primary care physician required payment for service (the nerve!).

In spite of the negative tone, these comments offered something beyond mere entertainment value – that is, proof that with regard to the dire circumstances facing Georgia’s and America’s ERs, some people just don’t get it. So, in response to these misinformed types, I gladly offer a few examples for purposes of enlightenment. If you are a taxpayer, prepare to be angry.

I once had a patient present to the ER complaining of “stiff hair” (I’m not making this up). It turns out, she had placed a straightener on her hair and, later that night, around 1:00AM, showed up asking if we had something that would remove the straightener – and all at taxpayer expense.

“Baby’s first picture” is a common scam. It works this way – young pregnant females wait until around 20 weeks gestation. Then, they call 911 complaining of pelvic pain and leaking fluid (which, of course, is a fabrication). This gets them a free ride to the ER and a complete work-up including trans-abdominal ultrasound during which the ultrasonographer captures images of the developing fetus for the medical record. The patient then asks for copies of these images which she later displays to her friends and family as “baby’s first picture” – and all at taxpayer expense.

For many years, the most shoplifted items in America were home pregnancy tests, that is, until these shoplifters discovered they could acquire them for free at ERs. So, nowadays, the scenario goes like this…Patient: “I’m eight weeks pregnant and I need a pregnancy test.” Triage nurse: “Have you been to your doctor for an exam?” Patient: “No, I need a pregnancy test first so I can get my Medicaid started.” Nurse: “Have you taken a home pregnancy test?” Patient: “No, I don’t have the money,” after which she gets a free pregnancy test – and all at taxpayer expense.

Opiate addicts frequent ERs complaining of various pain syndromes in attempts to acquire prescriptions for narcotics. A common scam follows: an addict presents complaining of flank pain from kidney stones because he knows the treatment often includes narcotics.  The doctor orders a urinalysis to evaluate for the presence of blood in the urine – no blood often means no kidney stones which often means no narcotic prescription. Of course, the addict knows this and comes prepared – he has acquired a lancet from a diabetic relative or friend and, when he goes into the bathroom to provide a urine sample, he pricks his finger with the lancet, sticks his finger into the sample and, voila, blood in the urine which likely means a prescription for narcotics – and all at taxpayer expense.

For additional perspective, consider an all too common scenario: A patient with a history of high blood pressure and diabetes calls 911 at 2:00AM complaining of right knee pain. He gives these answers to the following questions: How long has your knee been hurting? “Three months.” What have you taken for pain? “Nothing.” Did you injure your knee at work? “I don’t work.” Have you seen your doctor about your knee pain? “I ain’t got no doctor.” Who writes your prescriptions for your blood pressure and diabetes medication? “I go to the ER.” How will you get home when we are finished? “My family, they’re in the lobby” (having followed the ambulance to the hospital). So he gets an x-ray, is diagnosed with mild osteoarthritis (which, of course, isn’t an emergency and doesn’t justify ambulance transport), receives an injection for pain and a prescription, and goes on his way – and all at taxpayer expense.

Ah, and the ER scams go on and on and on…the person who calls 911 complaining of chest pain in order to get a ride to town; the alcoholic who drank his enter Social Security check and comes to the ER to get medication to manage his withdrawal symptoms; the weekend partier who presents on Sunday night seeking a work excuse in anticipation of a Monday morning hangover; members of the Friday Night Gun and Knife Club who shoot and stab each other over real or perceived slights and then get dropped off by friends in the ER parking lot or ambulance bay; the Sunday lunch crowd who, amazingly, never seem to get sick during church services but somehow manage to become acutely ill at the conclusion of the sermon; and the people who visit the ER instead of their doctor because their doctor charges a co-pay or they just don’t have time to make an appointment or they just don’t like waiting in the doctor’s office or whatever, whatever, whatever – and all at taxpayer expense.

Rescuing Georgia’s Rural Emergency Rooms

For Georgia and America to rescue their failing rural emergency rooms, state and federal legislators, hospital administrators, emergency medicine physicians, nurses, ancillary medical staff, patients, and the public at large must first come to terms with several simple and unavoidable truths:

1) Rural ERs are being abused by non-payers, drug-seekers, those looking for a work excuse or a free pregnancy test, and those who have no idea what the true purpose of an ER is.

2) Those in a position to do something about these problems aren’t doing anything meaningful about these problems.

3) Hospitals – even those listed as not-for-profit – are businesses, not charity organizations, and any hospital that is operated as a charity rather than a business will eventually fail (well, except maybe St. Jude’s).

4) Emergency physicians who refill maintenance medications including narcotics are partially to blame.

5) Malpractice lawyers aren’t to blame but social security and disability lawyers who encourage clients to visit emergency rooms to enhance their chances of a successful claim are partially to blame.

6) Most important, health care is not a right, rather, it is a personal responsibility.

For those who disagree, I invite you to pull a 24-hour shift with me in a rural ER to see for yourself. Unlike deluded Hollywood celebrities and disgruntled second-string NFL players grasping for their last 15 minutes of fame, my comments are based not upon something I heard at a party or read in Salon Magazine but, rather, on real-life, day-to-day (and night-to-night for that matter) experiences during the thousands of hours I’ve spent working as an emergency physician in several of Georgia’s rural ERs during the last nearly 20 years.

Working in a rural ER has an upside – saving a life, easing someone’s pain, making a sick child feel better. But there is a dark side, too, and only those who work in emergency medicine fully understand what I mean. There are those in society who want something for nothing, who demand much from the system but offer little or nothing in return, who believe the world owes them a living, and who accept no personal responsibility for their actions…and these people, it seems, frequent rural ERs in droves. The problem, at least from a policy standpoint, is that due to the insular and private nature of medicine in general, and emergency medicine in particular, the general public has little or no awareness of the abuse – if they did, they’d be outraged. To put the situation into financial perspective, every time you write that check to pay your exorbitant medical insurance premium, just know that you are paying for your own coverage and that of 8 or 10 other people you don’t even know.

To be sure, the problem is multi-factorial, as the above list attests. However, the most fundamental issue leading to the financial failure of rural ERs and hospitals is the leftist notion that health care is a right. For decades, beginning with President Roosevelt’s pre-World War II implementation of John Maynard Keynes hair-brained economic theories to the post-World War II influx of European socialists, those on the Left have attempted to indoctrinate Americans into believing all personal needs could be, and should be, met by the government. That led eventually to President Johnson’s colossal failure known as the “Great Society” program and recently culminated in President Obama’s \$20 trillion dollar national debt attributable mostly to the massive expansion of Medicaid and the food stamp program.

In fact, people have no more of a right to demand that someone else provide them with medical coverage than they have a right to fill a buggy with merchandise at Wal-Mart and walk out without paying or to demand their next door neighbor mow their lawn for them while sitting on their front porch drinking sweet tea. Until this segment of society finally comes to understand that health care isn’t a right but is an individual responsibility, rural ERs will continue to be abused and, as a result, will continue to fail.

Another Rural ER Bites The Dust

Tift Regional Health Center recently announced that its affiliate, Cook Medical Center in Adel, will close its emergency department next month. This action will leave the citizens of Adel and Cook County without immediate access to emergency department services. And it didn’t have to happen.

The reason for the forthcoming closure isn’t mismanagement on the part of administration or declining utilization or even a bad economy. The reason, actually, is a dirty little secret that the general public isn’t aware of and that those on the Left refuse to acknowledge…overutilization of emergency services by “self-pay” patients. Why the quotation marks around the term “self-pay?” Because, in the medical community, self-pay is a euphemism for “no-pay” as the vast majority of self-pay patients ultimately don’t pay their medical bills.

How do I know this? Because I am an emergency medicine physician and I once practiced in the emergency department at Cook Medical Center. While working there, I noted that the administrative and medical staff were excellent – caring, capable, and committed to patient care. Adel and Cook County, it seemed, had a good thing going with regard to its emergency department. But it was doomed, and I knew it. It was only a matter of time, and I said so, often. And now that time has come.

In addition to practicing medicine, I hold an MBA in management/finance and I can attest to the fact that there is no such thing as a successful business model in which a business loses more in revenue than it earns. That applies to hospitals as well – yet another fact the Left refuses to accept.

During my first shift at Cook, I treated a patient who had been to the ER 63 times that year already – it was only March – and he never paid a dime. On several occasions, he made multiple visits to the ER in the same day – on one occasion, six visits in 24 hours, all by ambulance. His objective, which he readily explained to me after I questioned the frequency of his visits, was that he had applied for disability and was told he was more likely to win his case if he had multiple ER visits in his medical record. When I brought this up to administration, I received the universal palms up sign along with the statement, “There is nothing we can do.”

A simple, if only partial, solution to this problem is known as a medical screening examination (MSE) in which patients are evaluated by the ER physician and if their complaints are deemed non-emergent, these patients are referred to their primary care provider or local clinic. In this regard, most hospital administrators are at fault for not establishing MSE programs due, they argue, to concerns over litigation.

The other dirty little secret is that federal and state lawmakers could pass legislation to correct these abuses but choose not to in an effort to avoid being seen as insensitive. By implication, these legislators would prefer a rural hospital close and deny services to an entire community rather than run the risk of being seen as denying coverage to a certain segment of the population – that is, the no-payers.

Maybe when all of Georgia’s rural hospitals close, legislators will finally heed the call to real action. My impression, based upon experience, is that this is merely wishful thinking. The recent effort to solve the financial shortfall by offering tax incentives to encourage businesses to donate money to rural hospitals, though well-intentioned, has little to no chance of succeeding. Why? Because this plan avoids the fundamental problem of refusing to place responsibility on those responsible – that is, on the no-payers. Don’t believe me? Wait and see. Of course, improved insurance reimbursement rates would help some, but this does nothing to address the reality that rural ERs are being abused and that those in a position to do something about it aren’t doing anything about it. The lack of state and federal leadership with regard to Georgia’s and America’s failing rural hospitals is at best a travesty and, at worst, a dereliction of duty by those holding public legislative office. To save these hospitals requires strength of character on the part of our legislators – that is to say, the strength to tell people when they choose to visit a rural ER that they should be prepared to pay their bill and not expect someone else to pay it for them.

Trump’s Promise, Congress’ Duty

Ask nearly any representative or senator serving in the U.S. Congress his or her opinion of term limits and you will most likely get the same response: “Term limits aren’t necessary. It’s up to the voters to decide how long a person serves in office.” Ah, if it were only that simple.

President-elect Donald Trump, in his Contract With The American Voter, pledged that on his first day in office, he would propose a constitutional amendment to impose term limits on all members of Congress. What a fantastic idea. And long overdue. The problem, of course, is getting such an amendment ratified.

On the surface, the knee-jerk response of these politicians that term limits aren’t necessary because “it’s up to the voters” sounds reasonable. After all, here in America – the world’s preeminent “democracy” (actually, a representative republic) – U.S. citizens of legal age have the right to vote and in exercising that right, decide collectively who they wish to represent them at all levels of government. So, from an intuitive perspective, there is nothing wrong with sending the same politician back to Congress term after term if that is the electorate’s will. The problem, of course, is that what is intuitive doesn’t always match what is reality.

Many members of Congress have a knack for getting elected and not much else. Most often these are the glad-handers – affectionately or derisively known as the “good-ole boys” (and girls). Armed with a permanent smile and an effervescent “never met a stranger” personality, these politicians win re-election cycle after cycle, not because of their legislative talents, but rather because of their singular ability to get people to like them and, therefore, to vote for them. As most voting is emotion-based, it is a reliable formula.

Once in office, there is the power of incumbency which, in a nutshell, is based in the fact that voters like to vote for a winner and having already won at least one election, the incumbent is most often viewed as just that, a winner. Of course, there is from time to time a wave of anti-incumbency, however, most congressional incumbents are able to schmooze their way through this occasional annoyance only to win re-election again, and again, until, ultimately, they become that dirtiest of all four-letter words – a career politician.

The problem with this system, which appears democratic on the surface, is that it tends ultimately – in the case of career politicians as least – to be anything but democratic. Why? One simple reason – the accumulation of power.

The longer a member of Congress stays in office, generally speaking, the more difficult it is for a newcomer to defeat him or her due to the simple fact of the power of incumbency. Further, the longer a member of Congress stays in office, in most cases, the larger his or her war chest becomes with regard to campaign finances. Of course, money isn’t everything in politics, just almost everything. Anyone who knows anything about campaigning knows that the person with the most money to spend has the best chance of winning, all other things being equal. Still further, the longer a member of Congress stays in office, the more likely he or she is to earn a powerful legislative position which tends to further insulate him or her from an effective challenge.

If the point of a democracy (or, rather, a representative republic) is to empower the voters, then such self-sustaining concentrations of power are antithetical to the essence of the “one person, one vote” concept of fair and effective self-government. Even Congress, itself, along with most state legislatures once realized the folly of allowing certain politicians to become entrenched in government by proposing and ratifying the 22nd Amendment limiting the president to two terms – this after President Franklin Roosevelt appeared determined to remain president forever or, well, at least until he died (which, of course, he managed to do).

If President-elect Trump keeps his promise to the American people to propose, on his first day in office, an amendment instituting term limits on members of Congress, he will have done something truly historic. If members of Congress support ratification of the amendment by the state legislatures, they will have done something beyond historic – they will have done their duty.

It is, perhaps, one of the greatest lines ever uttered in a Hollywood movie – “Villainy wears many masks, none so dangerous as the mask of virtue.” Spoken by Johnny Depp in the 1999 film, Sleepy Hollow, that one line describes the very essence of Hillary Clinton and her long, tortuous, and failed – thankfully – effort at becoming president of the United States.

What America, and the world, witnessed during Clinton’s 2016 presidential campaign was nothing less than the culmination of her 40-plus year assault on “truth, justice, and the American way” (to borrow a phrase). And it was all done in the name of virtue.

Yes, virtue. After all, Hillary Rodham Clinton has always claimed to be for the “little guy.” And what could be more virtuous than that? When it comes to Clinton, however, with regard to her being for the little guy, nothing could be further from the truth. In fact, she has said so herself on numerous occasions, such as the time, while addressing the National Automobile Dealers Association in New Orleans in 2014, she explained that she hadn’t driven a car in the past 18 years, – not the smartest choice of venues to make such an admission.

No, Hillary Rodham Clinton isn’t for the little guy. In fact, she probably doesn’t even know any, so long has she been isolated in her elitist, jet setting, \$25,000-a-plate fundraising dinner world. Truth is, she can hardly tolerate little guys as she demonstrated so clearly during her White House years when she once openly berated a White House electrician, there to change a light bulb, by shouting at him that all work was to be done while the First Family was away.

As a paragon of virtue, however, Hillary should be allowed such excesses, right? In fact, the former secretary of state’s virtue knows no bounds according to her ever-present entourage of star-struck assistants, fawning reporters, and assorted sycophants, wanna-bes and hanger-ons. Consider her virtue as demonstrated in its many forms throughout the years. There was the dutiful wife, virtuously standing by her husband as he cheated on her again, and again, and again, when, in fact, she was actively targeting his accusers with threats and character assassination campaigns; there was the committed progressive, virtuously promoting gay rights while, at the same time, accepting millions of dollars in donations from the Saudi government – the same government that sanctions the execution of homosexuals; there was the exalted stateswoman, jetting around the world, virtuously defending America’s interests abroad while at the same time selling influence through her and Bill’s sham philanthropy, the Clinton Global Initiative.

And the list of her virtues goes on, and on, and on – Whitewatergate, Filegate; stolen furniture from the White Housegate; cattle futuresgate; I was shot at by a sniper on the tarmac in Bosniagate; I once attempted to enlist in the Marinesgate; I was dead broke when I left the White Housegate; all of my grandparents are immigrantsgate; I am of Jewish ancestrygate; I thought I was allowed to use an illegal, secret, unsecure, personal server to send and receive top secret government emailgate; the 33,000 emails I deleted were personalgate; and, last but not least, what does it matter that four Americans were killed in Benghazi because I was an incompetent U.S. secretary of stategate.

Ambition can be a virtue when the goal is to improve one’s life and/or the lives of others. However, when the goal is self-aggrandizement and the accumulation of power for personal gain, ambition can be one of humanity’s darkest and most dangerous vices. “Power tends to corrupt, and absolute power corrupts absolutely,” said Lord Acton. In Hillary’s case, she wasn’t corrupted by power. Her pursuit of power was the result of an original corruption, a darkness that began long before her assent to power. During that climb, she likely attempted to cover her dark motivations with many masks. In the end, Hillary chose the most dangerous mask of all, a mask of virtue.

Never Trumpers And Holier Than Thouism

In their unrelenting attacks on conservatism, angry liberals utilize a literal arsenal of weapons – disinformation (a euphemism for lies), smear tactics, mislabeling, name calling, race baiting, transference, media bias, paid protesters, class warfare, propaganda, and various and sundry forms of deceit and deception. In fact, during the 2016 presidential election cycle alone, the Left persistently referred to conservatives as racists, bigots, xenophobes, misogynists, sexists, liars, cheats, opportunists, traditionalists, hacks, thugs, loons, crazies, Nazis, murderers, ignorant, stupid, intolerant, thickheaded and, worst of all in their minds, holier than thou.

The Left’s tactical objective is to convince voters that all conservatives are something that most aren’t. Their chronic failure to reach this objective is rooted in a persistent incongruence between their words and their actions. For example, it has now become commonplace for liberal protesters holding “Love Trumps Hate” signs to physically assault passing Trump supporters. Nevertheless, in all their childish rants, angry liberals have finally gotten it right with regard to at least one sub-group within the conservative movement. By referring to Never Trumpers as “holier than thou,” Lefties finally hit the nail on the head.

First of all, to be fair to the Never Trumpers, I understood their aversion, early in his campaign, to the billionaire developer with the wispy, nutmeg-colored comb-over coif. That’s because, up to that time, my impression of Trump – a loud mouthed, self-absorbed, narcissistic, womanizing, ostentatious, spoiled brat – was based upon various news snippets and sound bites regarding his often outrageous, in my opinion, behaviors. I mean, what kind of a man actually refers to himself as, “The Donald,” and requires others to do the same? Having grown up on a small farm in rural Georgia, the son of parents neither of whom had the opportunity to graduate high school, I couldn’t relate to a flamboyant, mega-rich New York City slicker on any conceivable level.

However, as the 2016 presidential campaign progressed, and the more I began to pay attention to Trump, the more his persona began to make sense to me – in the rough and tumble world of big city real estate development, pulling off big deals requires big personalities, a la The Donald. Eventually, it became clear to me there was more to him than pompous bloviation. Trump doesn’t drink, smoke, or do drugs; he is an extremely hard worker; he adores his children (all of whom are hardworking and successful in their own right and none of whom have been in drug/alcohol/sex rehab like so many children of the Left); he converts dilapidated properties into showcases; and he creates jobs and promotes economic opportunity. Sure, he has his faults, but who on the Left or among the Never Trumpers is qualified to cast the first stone? Not a one of them.

No one likes a liar (unless, of course, one is a liberal and the liar is Bill or Hillary Clinton) and, even worse, no one likes a hypocrite. And that is where the Left makes hay in their assaults on conservatives – by painting all conservatives with the Never Trumper holier than thou paint brush, liberals portray conservatives as rigid, judgmental, intolerant, sanctimonious, overly pious, and even hyper-religious. That shoe may fit Never Trumpers, but it doesn’t fit all conservatives.

At most, Never Trumpers should have viewed Trump as the sick view unpalatable medicine – sure, it tastes bad but, in the end, it’s for the best. However, holier than thouism wouldn’t allow it – Never Trumpers needed Trump to be something none of them ever were or ever could be – perfect. Of course, principles are important and no conservative should have been expected to discard his or her core beliefs and make a deal with the Devil just to win an election (though most liberals seem given to no such compunction). However, considering what was at stake – a Hillary Rodham Clinton presidency – Never Trumpers should have quickly gotten over themselves after the Republican primary and immediately supported Trump with great passion and gusto. At the very least, they should have kept their mouths shut. Their tacit support of Crooked Hillary through active efforts to undermine Trump’s campaign bordered on the politically traitorous. If The Donald proves to be a miserable failure as president, Never Trumpers will have their victory at the nation’s expense. But, if Trump succeeds, Never Trumpers will be served a nightly dinner of crow sprinkled with the bitter seasoning of holier than thouism.